Right to reimbursement

Courts in at least one state -- Florida -- say health plans should be accountable for payment delays or underpayments to out-of-network doctors treating emergency cases.

Editorial. Dec. 4, 2006.

The law often requires physicians and hospitals to provide emergency care. But the law can be a two-way street. Other statutes ensure -- at least when the patient is insured -- that those who have provided the care won't go wanting for payment.

It sounds simple enough. But health plans often have complicated the matter by determining that the law doesn't necessarily apply in cases where an out-of-network physician is the one delivering treatment.

Fortunately, courts are starting to recognize that health plans deserve to be called on the carpet for their actions.

Three Florida courts -- its Supreme Court and two state appellate courts -- have ruled recently that under the state's emergency treatment, HMO and prompt-pay statutes, physicians and hospitals may sue health plans whom they believe are engaging in delaying reimbursement or underpaying them when the checks do arrive.

With the right of redress established, the Florida courts have sent a clear signal to health plans in that state -- and a message that rightfully should resonate in other states where similar cases are being argued -- that they can be held accountable for their actions. This is just as physicians would be held accountable if they refused to provide mandated emergency care.

A friend-of-the-court brief written by the Florida Hospital Assn., the Florida College of Emergency Physicians, the Florida Medical Assn. and the AMA in Westside EKG Associates v. Foundation Health underscored the frustration of out-of-network physicians seeking payment for emergency care: